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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Skin cancer is the most frequent in Brazil and accounts for about 30&#37; of all recorded malignant tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has high cure rates if detected early but can result in significant morbidity&#44; if not correctly diagnosed and treated&#44; especially in tumors with more aggressive and infiltrative histopathological types&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Mohs micrographic surgery &#40;MMS&#41; is currently considered the most effective method for treating many types of skin cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is characterized by lesion identification&#44; accurate mapping of all process stages&#44; and complete evaluation of tumor margins&#46; The relationship between the presence of a neoplasm on histopathology and its correct location on the surgical map is essential for complete lesion resection and healthy tissue preservation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It offers the highest cure rates for many of the most frequent cutaneous neoplasms&#44; such as basal cell carcinoma &#40;BCC&#41; and squamous cell carcinoma &#40;SCC&#41; in their classic forms also in rare mixed forms&#44; including BCC with adnexal differentiation&#44; squamous or metatypical BCC or clear cell SCC&#46; There are also other uncommon skin tumors&#44; with high risk of recurrence&#44; for which there are no well-established criteria regarding treatment and that may benefit from this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Rare or uncommon skin tumors do not have an exact definition and in this group&#44; benign or malignant skin neoplasms of low prevalence can be included&#44; which&#44; in addition to being rare&#44; can also recur&#46; Because of the lack of uniformity regarding the reported cases&#44; the true incidence is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> They can be divided&#44; according to their histological origin&#44; into some groups&#44; with some main tumors&#46; Briefly&#44; they can be grouped as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Those of adnexal origin may show follicular differentiation&#44; such as trichilemmal carcinoma and trichoblastoma&#59; sebaceous differentiation&#44; such as sebaceous carcinoma&#59; or sudoriparous differentiation&#44; such as microcystic adnexal carcinoma &#40;MAC&#41; and spiradenoma&#46; MAC is an aggressive malignant neoplasm originating from the sweat glands&#44; with dense stroma surrounding the tumor islands and extensive local infiltration&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> There are also those of vascular origin&#44; such as angiosarcoma&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">One example of a tumor of neuroendocrine origin is Merkel cell carcinoma &#40;MCC&#41;&#44; an aggressive neuroendocrine skin tumor with increasing prevalence in recent years&#44; reaching 0&#46;7 cases per 100&#44;000 inhabitants in the USA&#46; It has a high rate of metastasis and mortality&#44; with a 5-year survival of 62&#37; in the early stages and 13&#46;5&#37; in the advanced stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;15&#8211;17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Also recognized is the group of neoplasms of fibrohistiocytic origin&#44; comprising neoplasms such as dermatofibrosarcoma protuberans &#40;DFSP&#41; and atypical fibroxanthoma &#40;AFX&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> DFSP is a slow-growing&#44; asymmetrical malignant tumor with an poorly defined subclinical extent&#46; Histopathologically&#44; there is diffuse infiltration of spindle cells&#44; with a storiform pattern&#46; DFSP has reported incidence rates ranging from 0&#46;8 to 5 per million inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A population study from 1972 to 2002 showed 4&#46;2 per million&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> AFX is a fibrohistiocytic tumor of intermediate malignant potential that accounts for about 0&#46;002&#37; of skin tumors&#44; according to a ten-year study from New Zealand&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There are also tumors of muscular&#44; adipocytic&#44; or cartilaginous origin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Many of these tumors do not have a prevalence and incidence estimate due to the small number of cases&#44; with studies based only on small reports&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main goal of treatment is an oncological cure&#44; but one should also aim to preserve function and maximum healthy tissue in addition to a satisfactory cosmetic result&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In relation to less prevalent skin tumors&#44; non-surgical methods are rarely indicated&#46; Radiotherapy and systemic treatments involving immunotherapy may be alternatives in patients with contraindications for the surgical procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Moreover&#44; in the case of rare skin tumors with a recurrent characteristic&#44; surgical methods in which it is not possible to assess the surgical margins&#44; such as electrocoagulation and cryosurgery&#44; are not routinely indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The most frequently used method is conventional surgery with wide margins&#44; characterized by tumor excision and surgical wound closure&#46; The visible lesion is removed with a standardized and variable safety margin&#44; according to the tumor type and characteristics&#46; The standardization of safety margins is established for BCC and SCC&#44; but it is not well established for less prevalent tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The surgical specimen is sent for anatomopathological evaluation&#46; The pathologist confirms the histopathological subtype and the involvement or not of the margins in the assessed sections&#46; Multiple sequential cuts are performed on the specimen&#59; however&#44; it is not possible to assess100&#37; of the margins&#44; which is done by sampling&#46; For this reason&#44; tumor escape may occur at an unassessed margin&#44; resulting in a false negative result&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Mohs micrographic surgery is the best-known method among the options of Micrographic Surgery with Total Intraoperative Margin Control &#40;MSTIOMC&#41;&#46; All margins are assessed during surgery&#44; with frozen sections and reconstruction during a single surgical time&#44; unlike conventional surgery and simple freezing&#44; which is also performed by sampling&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6&#44;25</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">MSTIOMC is the most effective technique in the treatment of cutaneous neoplasms&#46; The removal of the clinically delimited tumor mass is performed with a minimum safety margin&#44; which varies according to the histopathological tumor type&#46; A thorough mapping of all margins of the obtained fragment is necessary&#44; allowing a perfect correlation with the surgical defect left in the patient&#46; Markings are made on the specimen&#44; reference points&#44; and orientation between the tumor and the skin&#44; in addition to the fragment staining with different colors&#46; The colors are important for the identification and orientation of the studied margins&#44; in addition to the spatial location of an eventual tumor found in the fragments&#46; The mapping can be made on paper or digitally&#44; through photos and editing applications&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The samples are submitted to freezing in the cryostat and the slides are stained with hematoxylin &#38; eosin &#40;H&#38;E&#41; and viewed under an optical microscope for evaluation by the micrographic surgeon&#46; Once the presence of neoplasm is detected in any of the fragments&#44; the affected area is identified on the map&#44; so that a targeted resection of the additional fragment can be performed&#44; sparing healthy tissue&#46; The tumor excision ends when all margins are negative for neoplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Among the different methods of MSTIOMC&#44; there are the classic MMS at 45 degrees&#44; the variant MMS at 90 degrees&#44; used in the present study&#44; and the Munich Technique&#44; all of which have similar cure rates&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The choice of method will depend on the training and experience of the professional&#44; without consequences for the patient who will undergo the procedure&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">MMS&#44; despite being widely recognized for the treatment of several of these tumors&#44; both common and rare&#44; with superior cure rates&#44; remains underused&#46; Ideally&#44; it could be considered the first choice in high-risk&#44; primary&#44; or recurrent tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> However&#44; due to reduced availability&#44; higher cost of implantation and maintenance&#44; and the need for specialized professionals that have been trained in the method and cutaneous oncology during a long training process&#44; it is mainly indicated in recurrent tumors&#44; after several previous treatments&#44; which reduces its effectiveness&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Most studies published in MMS have as their topic the treatment of BCC and SCC&#44; the most common types in this group and which have well-established indication criteria&#46; There is&#44; however&#44; indication for surgical treatment for multiple less common tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Rare skin tumors are commonly treated by the conventional surgical technique with wide margins&#44; and there is no consensus regarding the standardization of these margins&#46; Nevertheless&#44; incomplete excisions and recurrence occur often&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;37&#8211;39</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Flohil et al&#46;&#44; in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported a study of rare tumors treated using MMS at a university center in the Netherlands&#46; The retrospective review included 80 rare tumors&#44; consisting of dermatofibrosarcoma protuberans &#40;33&#37;&#41;&#44; atypical fibroxanthoma &#40;27&#46;5&#37;&#41;&#44; Merkel cell carcinoma &#40;11&#46;25&#37;&#41;&#44; microcystic adnexal carcinoma &#40;10&#37;&#41;&#44; sebaceous carcinoma &#40;7&#46;5&#37;&#41;&#44; extramammary Paget&#39;s disease &#40;2&#46;5&#37;&#41;&#44; spiradenocarcinoma &#40;1&#46;25&#37;&#41;&#44; among others&#46; It concluded that MMS is an appropriate treatment for the rare tumors with only two cases of recurrence&#44; both atypical fibroxanthomas&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">DFSP is the rare tumor with the highest number of reports of treatment using MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;29</span></a> The subclinical spread of this neoplasm makes its complete removal difficult&#44; with high recurrence rates in case series&#46; Cernea et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> justify the indication of the MMS technique for the treatment of DFSP in the guidelines of the Brazilian Society of Dermatology&#44; based on the available evidence that indicates a lower rate of recurrence&#46; Although it is the rare tumor with the highest number of reports&#44; there is a lack of better quality&#44; randomized and controlled studies with longer follow-ups&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">This tumor has high recurrence rates&#44; reaching 26&#37; to 53&#37; in some case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19&#44;29</span></a> A systematic review gathered data on DFSP treated by MMS from 1995 to 2011&#44; including 23 non-randomized studies&#44; of which four were comparative ones&#46; The observed recurrence rate was 1&#46;1&#37; in the MMS group&#44; <span class="elsevierStyleItalic">versus</span> 6&#46;3&#37; in the conventional surgery group&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Although routinely indicated for malignant tumors&#44; MMS can also be used in cases of large&#44; poorly defined benign tumors&#44; with a high risk of recurrence&#46; One example is trichoblastoma&#44; a rare&#44; slow-growing&#44; well-circumscribed adnexal tumor&#46; Even though it is a benign tumor&#44; reports have shown trichoblastomas with a more aggressive course&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;39</span></a> Although rare&#44; the risk of malignant transformation exists and should be taken into account when indicating treatment and evaluating MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">No Brazilian studies have been found that assessed several histopathological types of less frequent skin tumors&#44; only individual case reports or case series&#44; mainly of DFSP&#44; the rare tumor most frequently treatded with MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;30</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Reports involving the use of MMS in the treatment of less common skin tumors are scarce&#44; but they report lower rates of recurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a> requiring further studies in this area&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Study design</span><p id="par0125" class="elsevierStylePara elsevierViewall">This was a retrospective observational study&#44; including all cases of rare skin tumors or less common variants of BCC and SCC treated using the 90-degree variant Mohs micrographic surgery technique&#44; carried out at the Division of Dermatology&#44; Hospital de Cl&#237;nicas&#44; Unicamp&#44; between October 2008 and April 2021&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Research ethics committee</span><p id="par0130" class="elsevierStylePara elsevierViewall">The study was approved by the Research Ethics Committee of the institution under counsel number 3&#44;113&#44;179&#44; including the Free and Informed Consent Term &#40;FICT&#41;&#46; The informed consent was signed by the patients at the time of their outpatient follow-up appointment&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data collection</span><p id="par0135" class="elsevierStylePara elsevierViewall">Data were collected by reviewing the medical files and photographic records of the procedures including a specific database of micrographic surgery at the service&#46; All patients were over 18 years of age and came from the Hospital Skin Tumor Outpatient Clinic&#46; After the procedure&#44; the participants were seen at periodic clinical follow-ups&#44; making it possible to assess tumor recurrence&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">All treated patients were identified and included&#44; at the time of the surgery&#44; in a single registry&#44; which allowed the accuracy of the collected data&#46; In this registry&#44; patient data such as name&#44; hospital registration number&#44; date of birth&#44; sex&#44; age at the time of surgery&#44; and date of procedure were included&#46; Neoplasm data&#44; such as histopathological type&#44; whether recurrent or primary&#44; were also recorded&#44; in addition to details of the procedure&#44; such as number of stages&#44; number of fragments&#44; reconstruction&#44; surgical map with photographic documentation&#44; and clinical evolution&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Inclusion criteria</span><p id="par0145" class="elsevierStylePara elsevierViewall">All patients over 18 years of age&#44; with a confirmed histopathological diagnosis of rare skin neoplasia or less prevalent variants of BCC and SCC&#44; submitted to surgical treatment using Mohs micrographic surgery from 10&#47;2008 to 04&#47;2021 were included&#46; The less prevalent variants of BCC and SCC that could be included were&#58; BCC with adnexal or trichoepitheliomatous differentiation&#44; metatypical BCC or basosquamous carcinoma&#44; clear cell SCC and acantholytic SCC&#46; The procedure was performed by dermatologists specialized in micrographic surgery&#44; certified by the Brazilian Society of Dermatology&#44; and followed the criteria established by the Research Ethics Committee&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Histopathological examination and surgical technique</span><p id="par0150" class="elsevierStylePara elsevierViewall">All patients were treated employing the 90-degree variant Mohs micrographic surgery technique&#44; characterized by the separation of the fragment into lateral and deep margins with a 90-degree section&#44; followed by cryostat freezing and 5-micron thick sections&#46; The prepared slides were stained with hematoxylin-eosin and then evaluated by micrographic surgeons&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a> As these were rare tumors&#44; the slides were also evaluated by a dermatopathologist&#46; After selecting the patients&#44; the slides prepared during the respective procedures were retrieved for photographic recording of the research&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Analysis of results</span><p id="par0155" class="elsevierStylePara elsevierViewall">A descriptive analysis of the rare tumors was carried out&#44; as well as the description of the technique according to the number of stages&#44; disease-free evolution&#44; and cases of recurrence&#46; Only the descriptive statistical analysis was performed&#44; using the SPSS Statistics 20 software for Windows&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">During the period from October 2008 to April 2021&#44; 437 tumors were operated on using the Mohs micrographic surgery technique and 22 &#40;5&#37;&#41; cases were selected because they were considered rare tumors or rare BCC and SCC variants&#46; The other 95&#37; corresponded to common subtypes of BCC and SCC&#44; in addition to a case of lentigo maligna&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding gender&#44; 12 &#40;54&#46;5&#37;&#41; of the cases were female and ten &#40;45&#46;5&#37;&#41; were male&#46; Regarding the location of the tumors&#44; 15 &#40;68&#46;2&#37;&#41; were located on the head and neck&#44; four &#40;18&#46;2&#37;&#41; on the trunk&#44; and three &#40;13&#46;6&#37;&#41; on the extremities&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In total&#44; 22 patients with a rare skin tumor were fully treated with MMS&#46; The tumors were three dermatofibrosarcomas protuberans&#44; two atypical fibroxanthomas&#44; two spiradenomas&#44; two atypical hypercellular fibrohistiocytomas&#44; one primary cutaneous adenocarcinoma&#44; one trichoblastoma&#44; one porocarcinoma&#44; one chondroid syringoma&#44; one cutaneous angiosarcoma&#44; one Merkel cell carcinoma&#44; and one sebaceous carcinoma&#46; Six other cases of rare variants of basal cell carcinoma and squamous cell carcinoma included four BCC with trichoepitheliomatous follicular differentiation&#44; one metatypical BCC&#44; and one clear-cell SCC&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The mean age of patients at the time of the MMS was 54 years&#46; The youngest patients were 25 years old and the oldest was 84 years old&#46; Seven patients were younger than 50 years &#40;three cases of dermatofibrosarcoma protuberans&#44; two hypercellular fibrohistiocytomas&#44; one adenocarcinoma&#44; and one atypical fibroxanthoma&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">There were no cases of recurrence during the mean follow-up of 72 months&#46; No case was excluded due to the minimum follow-up time&#44; justifying cases with different clinical follow-up times&#44; as described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; As all patients maintained their clinical follow-ups&#44; it was possible for all of them to be evaluated by a dermatologist at the time of data collection to identify possible tumor recurrence&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The three cases with the shortest follow-up time comprised a case of cutaneous angiosarcoma &#40;27 months&#41;&#44; a Merkel cell carcinoma &#40;17 months&#41;&#44; and a sebaceous carcinoma &#40;6 months&#41; but all of them are under strict clinical follow-up for recurrences and distant disease and were included aiming at emphasizing the applicability of the surgical technique for this group of tumors&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Among the selected cases&#44; 13 &#40;59&#46;1&#37;&#41; of them had already been submitted to previous conventional surgery&#59; however&#44; due to incomplete excision margins&#44; they were indicated for treatment with MMS&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the required number of MMS stages for complete tumor excision&#46; The only case that required three stages was a recurrent spiradenoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">In 14 &#40;63&#46;6&#37;&#41; cases&#44; the patients required complex reconstruction after the procedure&#44; involving grafts or flaps&#44; and in 8 &#40;36&#46;4&#37;&#41; there was the possibility of non-complex reconstruction&#44; by primary closure or by second intention&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> includes a description of the 22 treated cases&#44; summarizing the data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">This retrospective case series shows that MMS is an appropriate treatment for rare skin tumors&#46; In contrast with BCC and SCC&#44; which have clear indications for MMS performance&#44; by classifying lesions into high and low risk&#44; less prevalent neoplasms still do not have well-established criteria&#46; It may be indicated for primary or recurrent&#44; poorly defined lesions located in anatomical regions with the need to spare healthy tissue or with a high recurrence characteristic&#44; such as DFSP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> In relation to rare benign skin tumors&#44; it would be indicated in recurrent&#44; large&#44; poorly delimited lesions&#44; or those at risk of malignant transformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">With the benefit of a full assessment of tumor margins&#44; MMS provides lower recurrence rates also for this group of tumors but each case needs to be evaluated individually&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8&#44;26&#8211;36</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Less prevalent cutaneous neoplasms corresponded to approximately 5&#37; of all tumors treated at the service using the MMS technique during the 12-year period&#46; There were no cases of recurrence&#44; with an average of six years of follow-up&#44; and the majority of cases &#40;59&#46;1&#37;&#41; were tumors with previous incomplete excision and&#44; therefore&#44; a higher risk of recurrence&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">It was also observed that&#44; despite not having been selected because it is not a rare skin tumor&#44; the case of lentigo maligna treated with MMS with intraoperative immunohistochemistry reinforces the possibilities for expansion of the indications of the technique&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Immunohistochemistry&#44; although not widely available&#44; with a high cost and increased surgical time&#44; can be of benefit in the evaluation of many of these tumors during MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">There is some difficulty in defining rare tumors and determining incidence and prevalence data&#44; due to the small number of cases regarding some of them&#46; Several other tumors for which there have already been reports of treatment with MMS were not included in this series&#44; such as microcystic adnexal carcinoma and extramammary Paget&#39;s disease&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Although the study was carried out in a tertiary hospital&#44; a referral center for cutaneous oncology and high-complexity surgery&#44; with high demand&#44; the performance of MMS is limited by the availability of the technique&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It has also been observed that it is difficult to carry out prospective and randomized studies in a single research center&#44; involving less frequent neoplasms&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">There were no cases of local or distant recurrence in this study&#44; after an average of six years of follow-up&#44; which is in agreement with other data in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> A university center in the Netherlands reported a retrospective case series of rare tumors treated with MMS&#46; A total of 80 tumors were included and it was concluded that MMC is an appropriate treatment for this group of tumors&#44; with only two cases of recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Regarding the location of the lesions in this series&#44; 68&#46;2&#37; of the tumors were located in the head and neck&#44; which can be explained by the MMS indication criteria and not by the higher prevalence of these tumors in this location&#46; This is a region with a higher risk for recurrence and where there is also the need to spare healthy tissue&#46; In this anatomical topography&#44; the safety of a complete evaluation of the tumor margins prior to reconstruction of the surgical defect is also one of the criteria for choosing the method&#46; An exception is DFSP&#44; a neoplasm with the highest prevalence on the trunk and limbs&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">DFSP is the rare tumor with the highest number of studies with MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;29&#44;32</span></a> In 58 cases of DFSP&#44; the extent of tumor invasion was calculated by studying the margins using frozen sections used in MMS and it was observed that 15&#46;5&#37; of tumors would have been incompletely excised if the 3&#8239;cm surgical margin had been used&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> A retrospective Canadian study of 48 cases of primary DFSP&#44; 28 treated by conventional surgery and 20 by MMS&#44; found 21&#46;4&#37; of positive margins in the first group&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">It has been reported that DFSP is associated with more stages and large defects&#44; as there is no consensus regarding the initial margin&#44; which is greater compared to other tumors&#44; often starting at one cm&#46; Even so&#44; it is a smaller margin than the three cm margin frequently used in conventional surgery&#46; This study showed that three cases were treated with MMS&#44; incompletely excised in the first approach&#44; two of them with negative margins in only one stage&#46; Both cases were submitted to MMS soon after the identification of compromised margins in the conventional surgery&#59; however&#44; they still presented residual tumor&#46; The rapid indication of the procedure may justify obtaining free margins in the first stage&#44; with a less subclinical extension of the residual lesion&#46; The two cases have 138 and 110 months of follow-up each&#44; with no signs of recurrence&#46; The long follow-up time without evidence of clinical disease reinforces the appropriate indication of the surgical technique&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> depicts the histopathological characteristics of DFSP&#44; with deep and asymmetrical tumor infiltration&#44; which corroborates the indication of MMC&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Among other examples is trichoblastoma&#44; a rare&#44; slow-growing cutaneous adnexal tumor&#46; In this series&#44; there was one case of recurrent trichoblastoma in a 66-year-old female patient &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Negative margins were obtained in two stages&#44; with no signs of recurrence at ten years of follow-up&#46; Although benign&#44; there have been case reports of a more aggressive course&#44; especially in large&#44; recurrent tumors of previous long-term evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;39</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0265" class="elsevierStylePara elsevierViewall">A case of primary cutaneous adenocarcinoma was also included in this series&#44; diagnosed after multiple paraffin sections and a broad panel of immunohistochemistry&#44; in addition to an extensive and multidisciplinary investigation to exclude a possible primary site other than the skin&#46; There are few reports of adenocarcinoma-like tumors treated by MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In this peculiar case&#44; the difficulty in the initial definitive diagnosis of the lesion&#44; due to the non-specific clinical characteristics&#44; was associated with alterations in the anatomopathological examination and in the immunohistochemistry analysis&#44; which led to the need to rule out a cutaneous metastasis of a primary tumor elsewhere &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#41;&#46; After the diagnostic conclusion that it was a primary cutaneous adenocarcinoma&#44; the therapeutic option using Mohs micrographic surgery reinforced the importance of this surgical technique&#46; The patient has been under clinical follow-up for eight years&#44; with no recurrence of the skin lesion and no evidence of another primary site&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">It is also noteworthy that the case with the highest number of stages and fragments was a recurrent spiradenoma&#46; Described in 1956 by Kersting and Helwig&#44; spiradenoma is a rare&#44; undifferentiated or poorly differentiated benign neoplasm of the sweat glands&#46; There is a risk of malignant transformation&#44; particularly in older and larger lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The treatment of choice is surgical&#44; but there is no clear recommendation for margins&#46; Little is known about the behavior of these tumors&#44; as they are rare&#44; with few published cases&#46; MMS should be considered in recurrent&#44; large&#44; or critically-located spiradenomas to ensure complete excision and tissue sparing&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In this case&#44; it was a lesion with compromised margins in the first approach&#44; fast-growing in a few months&#44; and painful&#46; For this reason&#44; MMS was indicated and the fact that it required three stages to obtain negative margins corroborated the indication&#44; demonstrating that the lesion would have been incompletely removed with the conventional surgical technique<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;37&#44;38</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0285" class="elsevierStylePara elsevierViewall">Finally&#44; the inclusion of a case of sebaceous carcinoma of the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41; is highlighted&#46; It is a rare adnexal tumor&#44; and most are located in the periocular region&#46; They are characterized by being fast-growing tumors&#44; often underdiagnosed&#44; with a risk of distant metastasis&#44; in addition to the association with other visceral and cutaneous neoplasms in the Muir-Torre syndrome&#46; A Chinese study analyzed 360 cases located in the eyelids and in only 62&#46;5&#37; of them&#44; sebaceous carcinoma was the initial clinical hypothesis&#46; About 20&#37; included hypotheses of benign lesions such as chalazion&#44; blepharitis&#44; and nevus&#46; MMS was the technique of choice for treatment of 31&#46;9&#37; of these cases and showed better control of local recurrence&#44; with a five-year cure rate of about 90&#37;&#44; when compared to conventional surgery with cure rates varying from 60&#37; to 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0290" class="elsevierStylePara elsevierViewall">Currently&#44; surgical treatment is preferred treatment for all skin tumors&#44; with some indications for non-surgical treatment for superficial and less aggressive lesions&#44; such as superficial BCC&#44; or in patients with contraindications for the procedure&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Regarding rare tumors&#44; due to the absence of well-established treatment criteria and sufficient literature data&#44; the use of non-surgical techniques for initial lesions is rarely indicated&#46; Due to their recurrent characteristic&#44; being incompletely excised by conventional surgery with wide margins&#44; MMS indication is supported by literature data and the expansion of the method should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0300" class="elsevierStylePara elsevierViewall">This retrospective case series shows that Mohs micrographic surgery is an appropriate technique for the treatment of rare skin tumors&#46; Regarding the frequency&#44; they corresponded to approximately 5&#37; of all cases treated with MMS during the 12-year period with no recurrences observed after an average of six years of follow-up&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">With the benefit of a complete assessment of tumor margins associated with lower rates of recurrence reported in the literature&#44; the possibility of extending the uses of the method should be considered&#44; which could lead to better results&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Financial support</span><p id="par0310" class="elsevierStylePara elsevierViewall">The present study received support from Funadersp&#44; Fundo de Apoio &#224; Dermatologia de S&#227;o Paulo - Sebasti&#227;o Sampaio&#44; project n&#46; 86-2019&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors&#39; contributions</span><p id="par0315" class="elsevierStylePara elsevierViewall">Thais Helena Buffo&#58; Statistical analysis&#59; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Rafael Fantelli Stelini&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Juliana Yumi Massuda Serrano&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Luciana Takata Pontes&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Renata Ferreira Magalh&#227;es&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Aparecida Machado de Moraes&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0345" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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    "fechaRecibido" => "2021-07-21"
    "fechaAceptado" => "2022-01-07"
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            0 => "Acrospiroma"
            1 => "Adenocarcinoma"
            2 => "Carcinoma&#44; Merkel cell"
            3 => "Dermatofibrosarcoma"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mohs micrographic surgery is an established technique in the treatment of cutaneous neoplasms&#46; It offers higher cure rates and the main indications are non-melanoma malignant skin tumors&#46; Few studies have been performed on the treatment of rare tumors through this technique&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">To study rare skin tumors and rare variants of basal cell carcinoma and squamous cell carcinoma submitted to Mohs micrographic surgery in a tertiary service in relation to frequency&#44; disease-free evolution&#44; and applicability of this surgical procedure for this group of tumors&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective observational study including rare skin tumors and less common variants of basal cell carcinoma and squamous cell carcinoma treated using Mohs micrographic surgery&#44; between October 2008 and April 2021&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">During the study period&#44; 437 tumors were treated using Mohs micrographic surgery&#44; and 22 &#40;5&#37;&#41; rare skin tumors were selected&#46; The tumors comprised three dermatofibrosarcomas protuberans&#44; two atypical fibroxanthomas&#44; two spiradenomas&#44; two hypercellular fibrohistiocytomas&#44; one primary cutaneous adenocarcinoma&#44; one trichoblastoma&#44; one porocarcinoma&#44; one chondroid syringoma&#44; one cutaneous angiosarcoma&#44; one Merkel cell carcinoma&#44; and one sebaceous carcinoma&#46; Six other cases of rare basal cell carcinoma variants with trichoepitheliomatous differentiation&#44; metatypical basal cell carcinoma&#44; and clear cell squamous cell carcinoma were included&#46; There were no cases of recurrence after an average of six years of follow-up&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study on rare neoplasms carried out in a single referral center&#44; and this surgical technique isn&#8217;t widely available in the public service&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">This retrospective case series showed that Mohs micrographic surgery is an appropriate treatment for rare skin tumors&#46; They corresponded to 5&#37; of the tumors treated by the technique during a 12-year-period&#44; with no recurrences identified&#46;</p></span>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermatofibrosarcoma protuberans &#40;Paraffin-embeded section&#44; Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;top left image&#41;&#58; recurrent neoplasm&#44; invading the hypodermis on the right side of the image and&#44; on the left&#44; an area of cicatricial fibrosis and granulomatous foreign body reaction secondary to previous conventional surgery&#46; &#40;B&#41; &#40;top right image&#41;&#58; dense area of storiform pattern&#46; &#40;C and D&#41; &#40;bottom right and left images&#41;&#58; infiltrative periphery of the neoplasm&#44; with fascicles of monomorphic spindle cells&#44; invading fibroconnective tissue on the left&#44; and adipose tissue in both&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nodular lesion measuring approximately 1&#46;5&#8239;cm below the eyelid with a diagnosis of primary cutaneous adenocarcinoma&#46; Source&#58; Archives of Dermatology HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Primary cutaneous adenocarcinoma &#40;Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;image on the left&#41;&#58; 5&#8239;micron-thick frozen sections&#44; showing glandular structures infiltrating the reticular dermis&#44; associated with chronic inflammation&#46; &#40;B&#41; &#40;center image&#41;&#58; paraffin-embedded section showing neoplastic perineural infiltration&#46; &#40;C&#41; &#40;image on the right&#41;&#58; paraffin-embedded section&#44; panoramic view showing a poorly circumscribed tumor&#44; consisting of irregular glandular structures invading the dermis&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Scar on the right leg secondary to previous conventional surgery&#46; &#40;B&#41; Clinical delimitation of recurrent spiradenoma during MMS&#46; Source&#58; Archives of Dermatology HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Spiradenoma &#40;5-micron thick frozen sections stained with Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;image on the left&#41;&#58; multinodular pattern&#44; with relatively large and circumscribed nodules within the dermis and subcutaneous tissue&#46; &#40;B&#41; &#40;image on the right&#41;&#58; Basaloid cells of two types&#46; In the periphery they are small with hyperchromic nuclei and in the center or around small lumens they are larger with pale nuclei&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Image on the left&#58; Extraocular sebaceous carcinoma&#46; &#40;B&#41; &#40;Upper right image &#40;paraffin-embedded section&#41;&#58; poorly defined lobes of basaloid cells and poorly differentiated sebaceous cells&#46; Moderate atypia&#46; &#40;C&#41; &#40;lower right image 5&#8239;micron thick frozen section&#41;&#58; tumor debulking during Mohs micrographic surgery&#46; Source&#58; Archives of Dermatology HC-Unicamp&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rare cutaneous neoplasms</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adnexal</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follicular differentiation</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tricoblastoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trichoepithelioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trichilemmal carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sebaceous differentiation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sebaceous carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sudoriparous differentiation</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spiradenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hidradenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiosarcoma&#44; Kaposi sarcoma</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neural and neuroendocrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Merkel cell carcinoma</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrohistiocytic</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatofibroma&#59; atypical and cellular variants</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical fibroxanthoma</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatofibrosarcoma protuberans</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Muscular&#44; adipocytic and cartilaginous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leiomyosarcoma&#44; chondroma</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Rare cutaneous neoplasms divided according to histological origin and examples of each group&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;13</span></a>&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DFSP&#44; Dermatofibrosarcoma protuberans&#59; AFX&#44; Atypical fibroxanthoma&#59; SP&#44; Spiradenoma&#59; HF&#44; Hypercellular fibrohistiocytoma&#59; AdeCa&#44; Adenocarcinoma&#59; TRB&#44; Trichoblastoma&#59; PoCa&#44; Porocarcinoma&#59; CS&#44; Chondroid syringoma&#59; ANS&#44; Angiosarcoma&#59; MCC&#44; Merkel cell carcinoma&#59; SC&#44; Sebaceous carcinoma&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients and tumor characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">DFSP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AFX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AdeCa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TRB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PoCa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ANS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Others<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Total number of tumors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;45&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Head and neck&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15 &#40;68&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trunk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;18&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extremities&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;13&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Previous treatment</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;40&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete excision&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;59&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Original Article
Mohs micrographic surgery in rare cutaneous tumors: a retrospective study at a Brazilian tertiary university hospital
Thais Helena Buffoa,
Corresponding author
thaisbuffo@gmail.com

Corresponding author.
, Rafael Fantelli Stelinib, Juliana Yumi Massuda Serranoa, Luciana Takata Pontesa, Renata Ferreira Magalhãesa, Aparecida Machado de Moraesa
a Discipline of Dermatology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
b Department of Pathological Anatomy, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
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accurate mapping of all process stages&#44; and complete evaluation of tumor margins&#46; The relationship between the presence of a neoplasm on histopathology and its correct location on the surgical map is essential for complete lesion resection and healthy tissue preservation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It offers the highest cure rates for many of the most frequent cutaneous neoplasms&#44; such as basal cell carcinoma &#40;BCC&#41; and squamous cell carcinoma &#40;SCC&#41; in their classic forms also in rare mixed forms&#44; including BCC with adnexal differentiation&#44; squamous or metatypical BCC or clear cell SCC&#46; There are also other uncommon skin tumors&#44; with high risk of recurrence&#44; for which there are no well-established criteria regarding treatment and that may benefit from this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Rare or uncommon skin tumors do not have an exact definition and in this group&#44; benign or malignant skin neoplasms of low prevalence can be included&#44; which&#44; in addition to being rare&#44; can also recur&#46; Because of the lack of uniformity regarding the reported cases&#44; the true incidence is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> They can be divided&#44; according to their histological origin&#44; into some groups&#44; with some main tumors&#46; Briefly&#44; they can be grouped as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Those of adnexal origin may show follicular differentiation&#44; such as trichilemmal carcinoma and trichoblastoma&#59; sebaceous differentiation&#44; such as sebaceous carcinoma&#59; or sudoriparous differentiation&#44; such as microcystic adnexal carcinoma &#40;MAC&#41; and spiradenoma&#46; MAC is an aggressive malignant neoplasm originating from the sweat glands&#44; with dense stroma surrounding the tumor islands and extensive local infiltration&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> There are also those of vascular origin&#44; such as angiosarcoma&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">One example of a tumor of neuroendocrine origin is Merkel cell carcinoma &#40;MCC&#41;&#44; an aggressive neuroendocrine skin tumor with increasing prevalence in recent years&#44; reaching 0&#46;7 cases per 100&#44;000 inhabitants in the USA&#46; It has a high rate of metastasis and mortality&#44; with a 5-year survival of 62&#37; in the early stages and 13&#46;5&#37; in the advanced stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;15&#8211;17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Also recognized is the group of neoplasms of fibrohistiocytic origin&#44; comprising neoplasms such as dermatofibrosarcoma protuberans &#40;DFSP&#41; and atypical fibroxanthoma &#40;AFX&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> DFSP is a slow-growing&#44; asymmetrical malignant tumor with an poorly defined subclinical extent&#46; Histopathologically&#44; there is diffuse infiltration of spindle cells&#44; with a storiform pattern&#46; DFSP has reported incidence rates ranging from 0&#46;8 to 5 per million inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A population study from 1972 to 2002 showed 4&#46;2 per million&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> AFX is a fibrohistiocytic tumor of intermediate malignant potential that accounts for about 0&#46;002&#37; of skin tumors&#44; according to a ten-year study from New Zealand&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There are also tumors of muscular&#44; adipocytic&#44; or cartilaginous origin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Many of these tumors do not have a prevalence and incidence estimate due to the small number of cases&#44; with studies based only on small reports&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main goal of treatment is an oncological cure&#44; but one should also aim to preserve function and maximum healthy tissue in addition to a satisfactory cosmetic result&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In relation to less prevalent skin tumors&#44; non-surgical methods are rarely indicated&#46; Radiotherapy and systemic treatments involving immunotherapy may be alternatives in patients with contraindications for the surgical procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Moreover&#44; in the case of rare skin tumors with a recurrent characteristic&#44; surgical methods in which it is not possible to assess the surgical margins&#44; such as electrocoagulation and cryosurgery&#44; are not routinely indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The most frequently used method is conventional surgery with wide margins&#44; characterized by tumor excision and surgical wound closure&#46; The visible lesion is removed with a standardized and variable safety margin&#44; according to the tumor type and characteristics&#46; The standardization of safety margins is established for BCC and SCC&#44; but it is not well established for less prevalent tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The surgical specimen is sent for anatomopathological evaluation&#46; The pathologist confirms the histopathological subtype and the involvement or not of the margins in the assessed sections&#46; Multiple sequential cuts are performed on the specimen&#59; however&#44; it is not possible to assess100&#37; of the margins&#44; which is done by sampling&#46; For this reason&#44; tumor escape may occur at an unassessed margin&#44; resulting in a false negative result&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Mohs micrographic surgery is the best-known method among the options of Micrographic Surgery with Total Intraoperative Margin Control &#40;MSTIOMC&#41;&#46; All margins are assessed during surgery&#44; with frozen sections and reconstruction during a single surgical time&#44; unlike conventional surgery and simple freezing&#44; which is also performed by sampling&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6&#44;25</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">MSTIOMC is the most effective technique in the treatment of cutaneous neoplasms&#46; The removal of the clinically delimited tumor mass is performed with a minimum safety margin&#44; which varies according to the histopathological tumor type&#46; A thorough mapping of all margins of the obtained fragment is necessary&#44; allowing a perfect correlation with the surgical defect left in the patient&#46; Markings are made on the specimen&#44; reference points&#44; and orientation between the tumor and the skin&#44; in addition to the fragment staining with different colors&#46; The colors are important for the identification and orientation of the studied margins&#44; in addition to the spatial location of an eventual tumor found in the fragments&#46; The mapping can be made on paper or digitally&#44; through photos and editing applications&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The samples are submitted to freezing in the cryostat and the slides are stained with hematoxylin &#38; eosin &#40;H&#38;E&#41; and viewed under an optical microscope for evaluation by the micrographic surgeon&#46; Once the presence of neoplasm is detected in any of the fragments&#44; the affected area is identified on the map&#44; so that a targeted resection of the additional fragment can be performed&#44; sparing healthy tissue&#46; The tumor excision ends when all margins are negative for neoplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Among the different methods of MSTIOMC&#44; there are the classic MMS at 45 degrees&#44; the variant MMS at 90 degrees&#44; used in the present study&#44; and the Munich Technique&#44; all of which have similar cure rates&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The choice of method will depend on the training and experience of the professional&#44; without consequences for the patient who will undergo the procedure&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">MMS&#44; despite being widely recognized for the treatment of several of these tumors&#44; both common and rare&#44; with superior cure rates&#44; remains underused&#46; Ideally&#44; it could be considered the first choice in high-risk&#44; primary&#44; or recurrent tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> However&#44; due to reduced availability&#44; higher cost of implantation and maintenance&#44; and the need for specialized professionals that have been trained in the method and cutaneous oncology during a long training process&#44; it is mainly indicated in recurrent tumors&#44; after several previous treatments&#44; which reduces its effectiveness&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Most studies published in MMS have as their topic the treatment of BCC and SCC&#44; the most common types in this group and which have well-established indication criteria&#46; There is&#44; however&#44; indication for surgical treatment for multiple less common tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Rare skin tumors are commonly treated by the conventional surgical technique with wide margins&#44; and there is no consensus regarding the standardization of these margins&#46; Nevertheless&#44; incomplete excisions and recurrence occur often&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;37&#8211;39</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Flohil et al&#46;&#44; in 2017&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported a study of rare tumors treated using MMS at a university center in the Netherlands&#46; The retrospective review included 80 rare tumors&#44; consisting of dermatofibrosarcoma protuberans &#40;33&#37;&#41;&#44; atypical fibroxanthoma &#40;27&#46;5&#37;&#41;&#44; Merkel cell carcinoma &#40;11&#46;25&#37;&#41;&#44; microcystic adnexal carcinoma &#40;10&#37;&#41;&#44; sebaceous carcinoma &#40;7&#46;5&#37;&#41;&#44; extramammary Paget&#39;s disease &#40;2&#46;5&#37;&#41;&#44; spiradenocarcinoma &#40;1&#46;25&#37;&#41;&#44; among others&#46; It concluded that MMS is an appropriate treatment for the rare tumors with only two cases of recurrence&#44; both atypical fibroxanthomas&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">DFSP is the rare tumor with the highest number of reports of treatment using MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;29</span></a> The subclinical spread of this neoplasm makes its complete removal difficult&#44; with high recurrence rates in case series&#46; Cernea et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> justify the indication of the MMS technique for the treatment of DFSP in the guidelines of the Brazilian Society of Dermatology&#44; based on the available evidence that indicates a lower rate of recurrence&#46; Although it is the rare tumor with the highest number of reports&#44; there is a lack of better quality&#44; randomized and controlled studies with longer follow-ups&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">This tumor has high recurrence rates&#44; reaching 26&#37; to 53&#37; in some case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19&#44;29</span></a> A systematic review gathered data on DFSP treated by MMS from 1995 to 2011&#44; including 23 non-randomized studies&#44; of which four were comparative ones&#46; The observed recurrence rate was 1&#46;1&#37; in the MMS group&#44; <span class="elsevierStyleItalic">versus</span> 6&#46;3&#37; in the conventional surgery group&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Although routinely indicated for malignant tumors&#44; MMS can also be used in cases of large&#44; poorly defined benign tumors&#44; with a high risk of recurrence&#46; One example is trichoblastoma&#44; a rare&#44; slow-growing&#44; well-circumscribed adnexal tumor&#46; Even though it is a benign tumor&#44; reports have shown trichoblastomas with a more aggressive course&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;39</span></a> Although rare&#44; the risk of malignant transformation exists and should be taken into account when indicating treatment and evaluating MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">No Brazilian studies have been found that assessed several histopathological types of less frequent skin tumors&#44; only individual case reports or case series&#44; mainly of DFSP&#44; the rare tumor most frequently treatded with MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;30</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Reports involving the use of MMS in the treatment of less common skin tumors are scarce&#44; but they report lower rates of recurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a> requiring further studies in this area&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Study design</span><p id="par0125" class="elsevierStylePara elsevierViewall">This was a retrospective observational study&#44; including all cases of rare skin tumors or less common variants of BCC and SCC treated using the 90-degree variant Mohs micrographic surgery technique&#44; carried out at the Division of Dermatology&#44; Hospital de Cl&#237;nicas&#44; Unicamp&#44; between October 2008 and April 2021&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Research ethics committee</span><p id="par0130" class="elsevierStylePara elsevierViewall">The study was approved by the Research Ethics Committee of the institution under counsel number 3&#44;113&#44;179&#44; including the Free and Informed Consent Term &#40;FICT&#41;&#46; The informed consent was signed by the patients at the time of their outpatient follow-up appointment&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data collection</span><p id="par0135" class="elsevierStylePara elsevierViewall">Data were collected by reviewing the medical files and photographic records of the procedures including a specific database of micrographic surgery at the service&#46; All patients were over 18 years of age and came from the Hospital Skin Tumor Outpatient Clinic&#46; After the procedure&#44; the participants were seen at periodic clinical follow-ups&#44; making it possible to assess tumor recurrence&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">All treated patients were identified and included&#44; at the time of the surgery&#44; in a single registry&#44; which allowed the accuracy of the collected data&#46; In this registry&#44; patient data such as name&#44; hospital registration number&#44; date of birth&#44; sex&#44; age at the time of surgery&#44; and date of procedure were included&#46; Neoplasm data&#44; such as histopathological type&#44; whether recurrent or primary&#44; were also recorded&#44; in addition to details of the procedure&#44; such as number of stages&#44; number of fragments&#44; reconstruction&#44; surgical map with photographic documentation&#44; and clinical evolution&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Inclusion criteria</span><p id="par0145" class="elsevierStylePara elsevierViewall">All patients over 18 years of age&#44; with a confirmed histopathological diagnosis of rare skin neoplasia or less prevalent variants of BCC and SCC&#44; submitted to surgical treatment using Mohs micrographic surgery from 10&#47;2008 to 04&#47;2021 were included&#46; The less prevalent variants of BCC and SCC that could be included were&#58; BCC with adnexal or trichoepitheliomatous differentiation&#44; metatypical BCC or basosquamous carcinoma&#44; clear cell SCC and acantholytic SCC&#46; The procedure was performed by dermatologists specialized in micrographic surgery&#44; certified by the Brazilian Society of Dermatology&#44; and followed the criteria established by the Research Ethics Committee&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Histopathological examination and surgical technique</span><p id="par0150" class="elsevierStylePara elsevierViewall">All patients were treated employing the 90-degree variant Mohs micrographic surgery technique&#44; characterized by the separation of the fragment into lateral and deep margins with a 90-degree section&#44; followed by cryostat freezing and 5-micron thick sections&#46; The prepared slides were stained with hematoxylin-eosin and then evaluated by micrographic surgeons&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;25</span></a> As these were rare tumors&#44; the slides were also evaluated by a dermatopathologist&#46; After selecting the patients&#44; the slides prepared during the respective procedures were retrieved for photographic recording of the research&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Analysis of results</span><p id="par0155" class="elsevierStylePara elsevierViewall">A descriptive analysis of the rare tumors was carried out&#44; as well as the description of the technique according to the number of stages&#44; disease-free evolution&#44; and cases of recurrence&#46; Only the descriptive statistical analysis was performed&#44; using the SPSS Statistics 20 software for Windows&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">During the period from October 2008 to April 2021&#44; 437 tumors were operated on using the Mohs micrographic surgery technique and 22 &#40;5&#37;&#41; cases were selected because they were considered rare tumors or rare BCC and SCC variants&#46; The other 95&#37; corresponded to common subtypes of BCC and SCC&#44; in addition to a case of lentigo maligna&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding gender&#44; 12 &#40;54&#46;5&#37;&#41; of the cases were female and ten &#40;45&#46;5&#37;&#41; were male&#46; Regarding the location of the tumors&#44; 15 &#40;68&#46;2&#37;&#41; were located on the head and neck&#44; four &#40;18&#46;2&#37;&#41; on the trunk&#44; and three &#40;13&#46;6&#37;&#41; on the extremities&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In total&#44; 22 patients with a rare skin tumor were fully treated with MMS&#46; The tumors were three dermatofibrosarcomas protuberans&#44; two atypical fibroxanthomas&#44; two spiradenomas&#44; two atypical hypercellular fibrohistiocytomas&#44; one primary cutaneous adenocarcinoma&#44; one trichoblastoma&#44; one porocarcinoma&#44; one chondroid syringoma&#44; one cutaneous angiosarcoma&#44; one Merkel cell carcinoma&#44; and one sebaceous carcinoma&#46; Six other cases of rare variants of basal cell carcinoma and squamous cell carcinoma included four BCC with trichoepitheliomatous follicular differentiation&#44; one metatypical BCC&#44; and one clear-cell SCC&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The mean age of patients at the time of the MMS was 54 years&#46; The youngest patients were 25 years old and the oldest was 84 years old&#46; Seven patients were younger than 50 years &#40;three cases of dermatofibrosarcoma protuberans&#44; two hypercellular fibrohistiocytomas&#44; one adenocarcinoma&#44; and one atypical fibroxanthoma&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">There were no cases of recurrence during the mean follow-up of 72 months&#46; No case was excluded due to the minimum follow-up time&#44; justifying cases with different clinical follow-up times&#44; as described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; As all patients maintained their clinical follow-ups&#44; it was possible for all of them to be evaluated by a dermatologist at the time of data collection to identify possible tumor recurrence&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The three cases with the shortest follow-up time comprised a case of cutaneous angiosarcoma &#40;27 months&#41;&#44; a Merkel cell carcinoma &#40;17 months&#41;&#44; and a sebaceous carcinoma &#40;6 months&#41; but all of them are under strict clinical follow-up for recurrences and distant disease and were included aiming at emphasizing the applicability of the surgical technique for this group of tumors&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Among the selected cases&#44; 13 &#40;59&#46;1&#37;&#41; of them had already been submitted to previous conventional surgery&#59; however&#44; due to incomplete excision margins&#44; they were indicated for treatment with MMS&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the required number of MMS stages for complete tumor excision&#46; The only case that required three stages was a recurrent spiradenoma&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">In 14 &#40;63&#46;6&#37;&#41; cases&#44; the patients required complex reconstruction after the procedure&#44; involving grafts or flaps&#44; and in 8 &#40;36&#46;4&#37;&#41; there was the possibility of non-complex reconstruction&#44; by primary closure or by second intention&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> includes a description of the 22 treated cases&#44; summarizing the data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">This retrospective case series shows that MMS is an appropriate treatment for rare skin tumors&#46; In contrast with BCC and SCC&#44; which have clear indications for MMS performance&#44; by classifying lesions into high and low risk&#44; less prevalent neoplasms still do not have well-established criteria&#46; It may be indicated for primary or recurrent&#44; poorly defined lesions located in anatomical regions with the need to spare healthy tissue or with a high recurrence characteristic&#44; such as DFSP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> In relation to rare benign skin tumors&#44; it would be indicated in recurrent&#44; large&#44; poorly delimited lesions&#44; or those at risk of malignant transformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">With the benefit of a full assessment of tumor margins&#44; MMS provides lower recurrence rates also for this group of tumors but each case needs to be evaluated individually&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8&#44;26&#8211;36</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Less prevalent cutaneous neoplasms corresponded to approximately 5&#37; of all tumors treated at the service using the MMS technique during the 12-year period&#46; There were no cases of recurrence&#44; with an average of six years of follow-up&#44; and the majority of cases &#40;59&#46;1&#37;&#41; were tumors with previous incomplete excision and&#44; therefore&#44; a higher risk of recurrence&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">It was also observed that&#44; despite not having been selected because it is not a rare skin tumor&#44; the case of lentigo maligna treated with MMS with intraoperative immunohistochemistry reinforces the possibilities for expansion of the indications of the technique&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Immunohistochemistry&#44; although not widely available&#44; with a high cost and increased surgical time&#44; can be of benefit in the evaluation of many of these tumors during MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">There is some difficulty in defining rare tumors and determining incidence and prevalence data&#44; due to the small number of cases regarding some of them&#46; Several other tumors for which there have already been reports of treatment with MMS were not included in this series&#44; such as microcystic adnexal carcinoma and extramammary Paget&#39;s disease&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Although the study was carried out in a tertiary hospital&#44; a referral center for cutaneous oncology and high-complexity surgery&#44; with high demand&#44; the performance of MMS is limited by the availability of the technique&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It has also been observed that it is difficult to carry out prospective and randomized studies in a single research center&#44; involving less frequent neoplasms&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">There were no cases of local or distant recurrence in this study&#44; after an average of six years of follow-up&#44; which is in agreement with other data in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> A university center in the Netherlands reported a retrospective case series of rare tumors treated with MMS&#46; A total of 80 tumors were included and it was concluded that MMC is an appropriate treatment for this group of tumors&#44; with only two cases of recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">Regarding the location of the lesions in this series&#44; 68&#46;2&#37; of the tumors were located in the head and neck&#44; which can be explained by the MMS indication criteria and not by the higher prevalence of these tumors in this location&#46; This is a region with a higher risk for recurrence and where there is also the need to spare healthy tissue&#46; In this anatomical topography&#44; the safety of a complete evaluation of the tumor margins prior to reconstruction of the surgical defect is also one of the criteria for choosing the method&#46; An exception is DFSP&#44; a neoplasm with the highest prevalence on the trunk and limbs&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">DFSP is the rare tumor with the highest number of studies with MMS&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;29&#44;32</span></a> In 58 cases of DFSP&#44; the extent of tumor invasion was calculated by studying the margins using frozen sections used in MMS and it was observed that 15&#46;5&#37; of tumors would have been incompletely excised if the 3&#8239;cm surgical margin had been used&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> A retrospective Canadian study of 48 cases of primary DFSP&#44; 28 treated by conventional surgery and 20 by MMS&#44; found 21&#46;4&#37; of positive margins in the first group&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">It has been reported that DFSP is associated with more stages and large defects&#44; as there is no consensus regarding the initial margin&#44; which is greater compared to other tumors&#44; often starting at one cm&#46; Even so&#44; it is a smaller margin than the three cm margin frequently used in conventional surgery&#46; This study showed that three cases were treated with MMS&#44; incompletely excised in the first approach&#44; two of them with negative margins in only one stage&#46; Both cases were submitted to MMS soon after the identification of compromised margins in the conventional surgery&#59; however&#44; they still presented residual tumor&#46; The rapid indication of the procedure may justify obtaining free margins in the first stage&#44; with a less subclinical extension of the residual lesion&#46; The two cases have 138 and 110 months of follow-up each&#44; with no signs of recurrence&#46; The long follow-up time without evidence of clinical disease reinforces the appropriate indication of the surgical technique&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> depicts the histopathological characteristics of DFSP&#44; with deep and asymmetrical tumor infiltration&#44; which corroborates the indication of MMC&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Among other examples is trichoblastoma&#44; a rare&#44; slow-growing cutaneous adnexal tumor&#46; In this series&#44; there was one case of recurrent trichoblastoma in a 66-year-old female patient &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Negative margins were obtained in two stages&#44; with no signs of recurrence at ten years of follow-up&#46; Although benign&#44; there have been case reports of a more aggressive course&#44; especially in large&#44; recurrent tumors of previous long-term evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;39</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0265" class="elsevierStylePara elsevierViewall">A case of primary cutaneous adenocarcinoma was also included in this series&#44; diagnosed after multiple paraffin sections and a broad panel of immunohistochemistry&#44; in addition to an extensive and multidisciplinary investigation to exclude a possible primary site other than the skin&#46; There are few reports of adenocarcinoma-like tumors treated by MMS&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In this peculiar case&#44; the difficulty in the initial definitive diagnosis of the lesion&#44; due to the non-specific clinical characteristics&#44; was associated with alterations in the anatomopathological examination and in the immunohistochemistry analysis&#44; which led to the need to rule out a cutaneous metastasis of a primary tumor elsewhere &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#41;&#46; After the diagnostic conclusion that it was a primary cutaneous adenocarcinoma&#44; the therapeutic option using Mohs micrographic surgery reinforced the importance of this surgical technique&#46; The patient has been under clinical follow-up for eight years&#44; with no recurrence of the skin lesion and no evidence of another primary site&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">It is also noteworthy that the case with the highest number of stages and fragments was a recurrent spiradenoma&#46; Described in 1956 by Kersting and Helwig&#44; spiradenoma is a rare&#44; undifferentiated or poorly differentiated benign neoplasm of the sweat glands&#46; There is a risk of malignant transformation&#44; particularly in older and larger lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The treatment of choice is surgical&#44; but there is no clear recommendation for margins&#46; Little is known about the behavior of these tumors&#44; as they are rare&#44; with few published cases&#46; MMS should be considered in recurrent&#44; large&#44; or critically-located spiradenomas to ensure complete excision and tissue sparing&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In this case&#44; it was a lesion with compromised margins in the first approach&#44; fast-growing in a few months&#44; and painful&#46; For this reason&#44; MMS was indicated and the fact that it required three stages to obtain negative margins corroborated the indication&#44; demonstrating that the lesion would have been incompletely removed with the conventional surgical technique<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;37&#44;38</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0285" class="elsevierStylePara elsevierViewall">Finally&#44; the inclusion of a case of sebaceous carcinoma of the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41; is highlighted&#46; It is a rare adnexal tumor&#44; and most are located in the periocular region&#46; They are characterized by being fast-growing tumors&#44; often underdiagnosed&#44; with a risk of distant metastasis&#44; in addition to the association with other visceral and cutaneous neoplasms in the Muir-Torre syndrome&#46; A Chinese study analyzed 360 cases located in the eyelids and in only 62&#46;5&#37; of them&#44; sebaceous carcinoma was the initial clinical hypothesis&#46; About 20&#37; included hypotheses of benign lesions such as chalazion&#44; blepharitis&#44; and nevus&#46; MMS was the technique of choice for treatment of 31&#46;9&#37; of these cases and showed better control of local recurrence&#44; with a five-year cure rate of about 90&#37;&#44; when compared to conventional surgery with cure rates varying from 60&#37; to 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0290" class="elsevierStylePara elsevierViewall">Currently&#44; surgical treatment is preferred treatment for all skin tumors&#44; with some indications for non-surgical treatment for superficial and less aggressive lesions&#44; such as superficial BCC&#44; or in patients with contraindications for the procedure&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Regarding rare tumors&#44; due to the absence of well-established treatment criteria and sufficient literature data&#44; the use of non-surgical techniques for initial lesions is rarely indicated&#46; Due to their recurrent characteristic&#44; being incompletely excised by conventional surgery with wide margins&#44; MMS indication is supported by literature data and the expansion of the method should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;26&#8211;36</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0300" class="elsevierStylePara elsevierViewall">This retrospective case series shows that Mohs micrographic surgery is an appropriate technique for the treatment of rare skin tumors&#46; Regarding the frequency&#44; they corresponded to approximately 5&#37; of all cases treated with MMS during the 12-year period with no recurrences observed after an average of six years of follow-up&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">With the benefit of a complete assessment of tumor margins associated with lower rates of recurrence reported in the literature&#44; the possibility of extending the uses of the method should be considered&#44; which could lead to better results&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Financial support</span><p id="par0310" class="elsevierStylePara elsevierViewall">The present study received support from Funadersp&#44; Fundo de Apoio &#224; Dermatologia de S&#227;o Paulo - Sebasti&#227;o Sampaio&#44; project n&#46; 86-2019&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors&#39; contributions</span><p id="par0315" class="elsevierStylePara elsevierViewall">Thais Helena Buffo&#58; Statistical analysis&#59; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Rafael Fantelli Stelini&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Juliana Yumi Massuda Serrano&#58; Statistical analysis&#59; approval of the final version of the manuscript&#59; design and planning of the study&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Luciana Takata Pontes&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Renata Ferreira Magalh&#227;es&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Aparecida Machado de Moraes&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0345" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2021-07-21"
    "fechaAceptado" => "2022-01-07"
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            0 => "Acrospiroma"
            1 => "Adenocarcinoma"
            2 => "Carcinoma&#44; Merkel cell"
            3 => "Dermatofibrosarcoma"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Mohs micrographic surgery is an established technique in the treatment of cutaneous neoplasms&#46; It offers higher cure rates and the main indications are non-melanoma malignant skin tumors&#46; Few studies have been performed on the treatment of rare tumors through this technique&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">To study rare skin tumors and rare variants of basal cell carcinoma and squamous cell carcinoma submitted to Mohs micrographic surgery in a tertiary service in relation to frequency&#44; disease-free evolution&#44; and applicability of this surgical procedure for this group of tumors&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective observational study including rare skin tumors and less common variants of basal cell carcinoma and squamous cell carcinoma treated using Mohs micrographic surgery&#44; between October 2008 and April 2021&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">During the study period&#44; 437 tumors were treated using Mohs micrographic surgery&#44; and 22 &#40;5&#37;&#41; rare skin tumors were selected&#46; The tumors comprised three dermatofibrosarcomas protuberans&#44; two atypical fibroxanthomas&#44; two spiradenomas&#44; two hypercellular fibrohistiocytomas&#44; one primary cutaneous adenocarcinoma&#44; one trichoblastoma&#44; one porocarcinoma&#44; one chondroid syringoma&#44; one cutaneous angiosarcoma&#44; one Merkel cell carcinoma&#44; and one sebaceous carcinoma&#46; Six other cases of rare basal cell carcinoma variants with trichoepitheliomatous differentiation&#44; metatypical basal cell carcinoma&#44; and clear cell squamous cell carcinoma were included&#46; There were no cases of recurrence after an average of six years of follow-up&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study on rare neoplasms carried out in a single referral center&#44; and this surgical technique isn&#8217;t widely available in the public service&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">This retrospective case series showed that Mohs micrographic surgery is an appropriate treatment for rare skin tumors&#46; They corresponded to 5&#37; of the tumors treated by the technique during a 12-year-period&#44; with no recurrences identified&#46;</p></span>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermatofibrosarcoma protuberans &#40;Paraffin-embeded section&#44; Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;top left image&#41;&#58; recurrent neoplasm&#44; invading the hypodermis on the right side of the image and&#44; on the left&#44; an area of cicatricial fibrosis and granulomatous foreign body reaction secondary to previous conventional surgery&#46; &#40;B&#41; &#40;top right image&#41;&#58; dense area of storiform pattern&#46; &#40;C and D&#41; &#40;bottom right and left images&#41;&#58; infiltrative periphery of the neoplasm&#44; with fascicles of monomorphic spindle cells&#44; invading fibroconnective tissue on the left&#44; and adipose tissue in both&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nodular lesion measuring approximately 1&#46;5&#8239;cm below the eyelid with a diagnosis of primary cutaneous adenocarcinoma&#46; Source&#58; Archives of Dermatology HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Primary cutaneous adenocarcinoma &#40;Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;image on the left&#41;&#58; 5&#8239;micron-thick frozen sections&#44; showing glandular structures infiltrating the reticular dermis&#44; associated with chronic inflammation&#46; &#40;B&#41; &#40;center image&#41;&#58; paraffin-embedded section showing neoplastic perineural infiltration&#46; &#40;C&#41; &#40;image on the right&#41;&#58; paraffin-embedded section&#44; panoramic view showing a poorly circumscribed tumor&#44; consisting of irregular glandular structures invading the dermis&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Scar on the right leg secondary to previous conventional surgery&#46; &#40;B&#41; Clinical delimitation of recurrent spiradenoma during MMS&#46; Source&#58; Archives of Dermatology HC-Unicamp&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Spiradenoma &#40;5-micron thick frozen sections stained with Hematoxylin &#38; eosin&#41;&#46; &#40;A&#41; &#40;image on the left&#41;&#58; multinodular pattern&#44; with relatively large and circumscribed nodules within the dermis and subcutaneous tissue&#46; &#40;B&#41; &#40;image on the right&#41;&#58; Basaloid cells of two types&#46; In the periphery they are small with hyperchromic nuclei and in the center or around small lumens they are larger with pale nuclei&#46; Source&#58; Archives of Dermatology&#47;Pathological Anatomy HC-Unicamp&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rare cutaneous neoplasms</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " rowspan="6" align="left" valign="\n
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                  \t\t\t\t">Adnexal</td><td class="td" title="\n
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                  \t\t\t\t">Follicular differentiation</td><td class="td" title="\n
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                  \t\t\t\t">Tricoblastoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Trichoepithelioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Trichilemmal carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Sebaceous differentiation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Sebaceous carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Sudoriparous differentiation</td><td class="td" title="\n
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                  \t\t\t\t">Spiradenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hidradenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiosarcoma&#44; Kaposi sarcoma</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neural and neuroendocrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Merkel cell carcinoma</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrohistiocytic</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatofibroma&#59; atypical and cellular variants</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical fibroxanthoma</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatofibrosarcoma protuberans</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Muscular&#44; adipocytic and cartilaginous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leiomyosarcoma&#44; chondroma</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Rare cutaneous neoplasms divided according to histological origin and examples of each group&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;13</span></a>&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DFSP&#44; Dermatofibrosarcoma protuberans&#59; AFX&#44; Atypical fibroxanthoma&#59; SP&#44; Spiradenoma&#59; HF&#44; Hypercellular fibrohistiocytoma&#59; AdeCa&#44; Adenocarcinoma&#59; TRB&#44; Trichoblastoma&#59; PoCa&#44; Porocarcinoma&#59; CS&#44; Chondroid syringoma&#59; ANS&#44; Angiosarcoma&#59; MCC&#44; Merkel cell carcinoma&#59; SC&#44; Sebaceous carcinoma&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients and tumor characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">DFSP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AFX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AdeCa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TRB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PoCa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ANS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Others<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Total number of tumors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;45&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trunk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;18&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Extremities&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;13&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Previous treatment</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;40&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete excision&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;59&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Reconstruction</span>&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 03650596
Original language: English
DOI:10.1016/j.abd.2022.01.009
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